Policy implications

Question II: How could community-based approaches become part of the HAT control policy and implementation?

Current HAT strategies aim to eliminate HAT as a ‘public health problem’ by 2020 [5, 249], but community participation is virtually absent [50], indicating that this approach is not a current priority. My research has shown that a number of benefits could arise from active community involvement in tsetse control, and particularly with involvement of women.

I synthesized the findings from all research phases to document the potential for community-based approaches to improve current policy and practice. In Chapter 1 and 3 I explored the assumption that communities can move from no participation to active participation in tsetse control, but that there will

140 be forces driving this change as well as resisting it. My thesis started with a theoretical approach, that of ‘force field analysis’ [176, 177] as used in organizational management; in this section, I revisit this theoretical framework to illustrate various factors working for and against community participation, from the perspective of the community and other stakeholders, derived from my research.

Figure 7.1 (adapted from [177]) illustrates the main driving and resisting forces occurring at the village (orange) or national and international level of stakeholders36 _{(blue). Strong engagement at the village} level and global and national initiatives to eliminate HAT generating new energy and a sense of commitment were some of the key driving forces. No resisting forces originated at village level providing there is flexibility in the timing of interventions and provision of equipment to perform tasks (as already discussed in section 7.3). The main resisting forces were lack of engagement of policy stakeholders with HAT-affected communities and their lack of understanding of community-based approaches.

36 _{Interviewed national and international stakeholders shared the same perceptions on illustrated areas and are} therefore joined under the same colour scheme in Figure 7.1.

141 Lewin [176] argues that change can be implemented by either adding forces that are pushing into desired direction, or reducing the resisting forces. In both cases the change will be achieved, but the secondary impact will be different. For instance, when forces are added into desired direction, this will result in increase of tension and higher emotional response in people affected by the change. On the contrary, when force is applied in reducing resisting forces, less tension will be triggered as a secondary effect (ibid.). Applying this theoretical approach, I discuss potential ways in which ‘driving and resisting forces’ could be managed in relation to future HAT strategies, based on community and women participation.

Reinforcing driving forces

Commitment to eliminate HAT is an opportunity

While decision-makers interviewed in this study showed positive attitudes towards community participation, the process of integrating this approach into policy and practice is not straightforward. Positive impacts of community-participation, for instance, have been previously documented [125, 126, 130, 132, 250], but this has not resulted in integration of this approach into HAT control strategies. Elimination plans provide a new opportunity for this change to occur.

In the context of the factors that facilitate translation of the research evidence into policy and practice, several findings, recorded in my research could potentially foster this process. Gilson et al. [166] for instance propose that research findings have to be shaped around implementation. My pilot study, which showed cost-cutting benefits and demonstrated feasibility of women-led intervention, is an example of that. Furthermore, personal networks among researchers, policy-makers and programme planners, which were suggested as a vital element for strengthening research influence [165], already exist in HAT control arena. Favourable timing, characterized by defined goal to eliminate HAT and stakeholders’ perception that this goal is unachievable without community support, further assists in lobbying for this approach. More frequent and better targeted contact with key institutions and individuals could occur during public meetings such as annual PATTEC (Pan-African Tsetse and Trypanosomiasis Eradication Campaign) meetings, WHO stakeholders meetings and international conferences focusing on tropical health.

Engaging communities as advocates

Another strong argument for adoption of this approach is that the community living under the threat of HAT is willing, motivated and skilled to be involved in efforts against this disease. This argument is stronger, potentially, if members of the community make these statements and advocate for change. Women demonstrated good negotiation skills and confidence through the role play, as well as insights

142 into the decision making process, which makes them excellent candidates to act as ambassadors for their communities and demand for programmes to help them to fulfil their health needs. UNICEF, acknowledges that providing the opportunities for beneficiary community to demand their rights, serves both ways: ‘right holders’ (community), receive adequate support defined by their rights and ‘duty bearers’ (health delivery programmes) are able to fulfil their duty towards ‘right-holders’. This process, as an example of effective advocacy, was described as leading towards change in policies, attitudes and action [163].

An absence of community representatives at the stakeholders’ meetings [5] clearly shows that community views have not yet been taken into consideration. To adopt a community approach the culture of decision- making process and decision-makers must change. The community would need to be provided with the opportunity for their voice to be heard. This could have been achieved through the personal contact between community representatives and policy makers or through videos recording their views (an example in Appendix D1) and distributed to the relevant audience.

Reducing resisting forces

Building up knowledge and skills on community-based approaches

Following the framework of the ’force field analysis’ [176] efforts to reduce resisting forces are more important than reinforcement of driving forces since this results in less tensions. The main resisting forces recorded in my analysis were associated with the lack of policy engagement with beneficiary communities. Discussions with stakeholders on this topic revealed that this is partly related to a widespread lack of skills and knowledge on how to plan and implement community-based interventions. Accordingly, there is a pressing need for more social scientists working in this arena to provide decision-makers and policy- planners with the requisite awareness, skills and capacities.

The reservation about involving women, expressed by some programme planners and implementers, was related to tsetse control being considered as male domain. As women in West Nile demonstrated, the use of tiny targets and management of control operation was seen as feasible by perspective of women. The conceptual shift is therefore needed among leaders in tsetse control to acknowledge that responsibilities related with planning and implementation of tsetse control could be shared with women. Lobbying could focus on raising awareness on gender imbalance at more senior positions and the barriers that this imbalance creates for promotion and implementation of women-led interventions.

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Engagement with the communities driven by donors’ priorities

One way of improving trust in community-based approaches is to promote interactions of all the stakeholders with the beneficiary community and discuss related concerns directly with them. If donors are committed to community-based approaches, then there is a greater likelihood of this approach being accepted by all stakeholders. One example, where this level of commitment exists, is a dengue elimination programme [251]. A group of dedicated social scientists were involved and everyone, including senior project staff, interacted with the community in a collaborative manner. As a result the programme achieved support from the host community and other local and state officials also engaged in the process (ibid.). Similar examples of collaboration and integration of all stakeholders, providing a mutual learning experience, are needed in tsetse control.

This prioritization, set by donors is also likely to ensure that engagement with communities is not overridden by other professional or non-personal priorities. Results in Chapter 6, for instance, showed that community-based approaches partially but not wholly coincide with senior decision-maker’s objectives. Scoones [172], who interviewed stakeholders with power and influence over research agenda, policy and funding in HAT, also found that motivation was driven, in part, by personal goals. He attributed researchers’ lack of willingness to hand over tsetse control operations to local communities to the former’s attempts to protect their power and prestige. This indicates that some effort will be required to push community-based approaches to overcome such personal and political priorities, but donors could influence and drive this change.

I have argued that HAT programme planners and decision-makers has partly already been in favour for community-based approaches. An enthusiasm to promote such approaches combined with a period when HAT elimination efforts are high on national and global stakeholders’ agenda, provide a historical opportunity which should not be missed. These research results feed into practical guidelines for such changes to occur.